Welcome to the Infinity Edition of Airway Management in Emergencies

​It's been too long, almost 7 years since the last edition of our textbook Airway Management in Emergencies! The airway however remains the same; a dark hole guarded by a towering epiglottis hinging over its triangular entry, framed by pearly white cords, where the wind blows the nutrients and byproducts of life back and forth. Ok enough with my attempt at airway poetry... From the Preface of the Infinity edition:

I (GK) completed my internship in 1990 on a Wednesday. On Friday we moved to a small town 6 hours away from where I had previously called home. On Monday I had a full office booked after which I was due to do my first emerg shift. I was blissfully ignorant, a perfect example of Dunning and Kruger's now famous work, "Unskilled and Unaware of It".[1] It was an overwhelming first shift for me that delivered both excitement and fear. It was the latter emotion (fear), that ultimately motivated me to go back to school and complete a residency in emergency medicine. The transition to independent practice after 4 years of training had definitely improved my confidence, but still I felt an almost dysfunctional anxiety when managing an airway without the protective umbrella of an attending at the foot of the bed.

The "AB" of the ABC's rarely proceeds as a stepwise progression of an ATLS-like algorithm and regardless of patient outcome it seems that once the airway is done, the clinician's anxiously elevated heart rate will often return to a near normal rate. These anxious moments can take control of a disproportionate amount of our brain's cognitive capacity when managing the airway of an acutely ill or injured patient. In retrospect, I often wonder whether my reaction was exaggerated by the fact that emergency medicine in the early 90's was still an emerging specialty and we had little external support in performing procedures such as an RSI, which was previously owned by anesthetists and performed almost exclusively in the operating room. "We were taking life away from the patient in using paralytics outside of the OR. "You'd better be damned sure you get the tube in the right hole" an anesthetist staff told me during my residency. I still hear his voice every time I intubate and while early in my career I viewed his words as an assault on our EM specialty, I don't think that was his intent. Safe and effective airway management in the acute care setting often requires complex decision making and skill execution in an austere environment and we need to be better than good in caring for these sick patients. Airway management is much more than putting the tube in the hole and airway management education deserves more attention than what can be provided in an off-service anesthesia rotation or an ATLS course.

A very significant proportion of emergency departments around the world are by necessity staffed with family physicians with minimal formal training in emergency medicine. Airway management in an acute care setting can be frightening for many of us. For those without additional training and few opportunities to attain and maintain resuscitation skills, the need to manage an airway in a critically ill or injured patient can be overwhelming. How to deal competency challenges associated with high acuity, low opportunity clinical scenarios remains an obstacle for educators and clinicians. The answer in part must involve simulation. The Canadian AIME (Airway Interventions and Management in Emergencies) course been using simulation to teach airway management for close to 20 years and is taught by clinicians with experience in both large centres and smaller ones with limited resources. It has been customized to the needs of the clinician and has been taught to nurses, paramedics, physician assistants, military medics and physicians. More recently we have had the great fortune of offering the AIME Advanced cadaver program, a procedure based educational experience using the highest fidelity simulator possible, the human body.

Notwithstanding, AIME or any other airway course cannot make someone competent whether it be a 1 day, 2 day, one week or several months educational experience. Competence comes with time and deliberate practice.[2] AIME and other airway programs can only serve as a recalibrated foundation for the clinician. A name on a tag followed by credential letters acknowledges that its bearer has been educated, graduated, passed an exam, and has achieved (as assessed) expected competencies within their domain of practice. However, whether a clinician has attained competence will mean very little if they have not taken deliberate steps to maintain their skills. Being a good clinician has little to do with the letters after your name as there is no endpoint for competence. Your clinician designation, whether it be MD, RN, PA or CCP should be considered as a declaration of commitment and accountability, to be active lifelong learners for the duration of your career. Neither anesthesia nor emergency medicine 'own the airway ' - the patient is the only one to hold that right. The clinicians best suited to manage the airway may have little to do with what their ID tags say and more to do with who is (or can be) available and has the skill to manage the patient at the time of need.

Depending on the context of the case, safe management of a patient's airway may be as simple as applying high flow oxygen through standard nasal prongs in combination with reservoir mask or as complex as performing an awake flexible endoscopic intubation. Textbooks and guidelines tend to present an approach to airway management that assumes unlimited resources and skill mastery with an array of available devices. While we agree for the need to present an airway management approach based on what the patient may need, the prescribed approach may not be safe for many contextual reasons. Few of us may achieve the level of skill mastery in using a growing menu of available airway devices. However, this is not an excuse to ignore potentially new, effective interventions by labelling them as too complex or unlikely to be required. Ericsson, I believe would agree that competence and skill mastery should have no endpoint and by definition lifelong learning requires effort and challenge throughout a clinicians career.[2] Pat Croskerry describes 'gambler's fallacy' as a cognitive disposition where we predict a future outcome (e.g. the need to perform a cricothyrotomy) based on our own experience/inexperience ("I've never had to do it").[3] This complacency breeds fear and potential incompetence in the clinician and creates danger for the patient. Doing what you do routinely doesn't make you an expert - routinely challenging your routine does.

Thousands of clinicians have taken the AIME course over the years, first using our self published manual and subsequently our 2 published editions of the textbook, Airway Management in Emergencies. We have been through hundreds of versions of our slides, changing content based on new literature, clinical experience and/or tips and pearls learned from teaching, clinical practice, and having regular access to resources such as clinical cadavers. The textbook cycle can be a painful process of thousands of hours of write-rewrite-revise-repeat only to become outdated based on new information from the literature and other real-time dissemination sources. Measured against the a rubric of 'value added' ("Petrie Triangle" ) writing a medical textbook may score poorly for the authors or editors.[4] And so despite the fact that we may on occasion begrudge the 'lost time' involved with writing, travel and teaching, it is without fail that after every airway program, we find ourselves saying "we can't stop". The need remains real and significant, and although it may sound clichéd, we do believe that far more lives have been saved by teaching and supporting clinician learners, than all of the hands-on saves we have collectively made to date in our clinical careers. These two factors, a rapidly growing/changing knowledge and skill landscape and the need to support clinicians working in the trenches now and in the future, was motivation to release our work into the world of FOAMed and create a customized publishing platform for the Airway Management in Emergencies, the Infinity EditionOur plan is to release chapters as they are produced and edited, and update the material on a more real-time basis as dictated by evidence, experience and feedback from our readers.

We hope you are motivated to learn and challenge your current skill set as you read our text. Thanks for taking the time.

George and Adam

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